The number of hospitalized patients being co-managed by emergency physicians (EPs) and hospitalists is increasing throughout the United States, as primary care providers and medical subspecialists limit their inpatient duties. In fact, emergency medicine and hospital medicine are second only to primary care as the largest group of physicians in the country. “It’s not uncommon for patients to be admitted through the ED and discharged after several days, after being seen only by EPs and hospitalists,” says Charles V. Pollack Jr., MA, MD, FACEP, FAAEM, FAHA. “Both specialties are typically represented 24 hours a day in hospitals.”
In many cases, EPs and hospitalists are often the only attending physicians after hours in the hospital. “They share a common practice space and govern decisions about the use of the most expensive care in medicine,” Dr. Pollack says. “However, the collaboration between EPs and hospitalists has traditionally been limited to bedside conversations when patients are admitted from the ED to hospital medicine services. This leaves hospitals vulnerable to missing opportunities to improve quality of care while also reducing costs of care.”
Stop, Collaborate, & Listen
With the growing importance of shared patient care between EPs and hospitalists, improved collaboration is essential and overdue. To further expand upon the need for better collaboration between EPs and hospitalists, Dr. Pollack co-authored a review on the topic and a call to action with Alpesh Amin, MD, MBA, MACP, SFHM, in issues of the Journal of Emergency Medicine and the American Journal of Medicine. Dr. Amin says this collaboration is important to enhancing care. “Better collaboration can facilitate communication, develop teamwork, improve efficiency, and encourage fewer breakdowns in care,” he says. “The goal should be to provide seamless opportunities for care and to help develop clinical pathways and guidelines across these specialties.”
To achieve the most efficient hospital care and optimize outcomes, EPs and hospitalists need to move out of their “silos,” according to Drs. Amin and Pollack. “Efforts are needed to ensure that these specialties work well together in a concerted effort to meet quality, customer service, length of stay, and throughput demands,” adds Dr. Amin. “The collaboration needs to be well organized, with concrete interventions for enhancing this alliance [Table 1].”
“Hospitalists, EPs, and a combination of the two are increasingly managing cardiovascular disease, stroke, COPD, and pneumonia, among other common disease states presenting to EDs,” explains Dr. Pollack. “Simple interventions to increase collaboration between EPs and hospitalists are available and should be implemented [online exclusive Table 2]. It’s more important than ever to ensure that patients are managed consistently across a continuum of care. This can best be accomplished by having EPs and hospitalists work together throughout hospitalizations so we can optimize follow-up care and perhaps avoid preventable readmissions.”
Establishing Protocols for Collaboration
Drs. Amin and Pollack agree that EPs and hospitalists need to take extra steps toward collaborating to ensure consistency of care as patients are transitioned from EDs to hospital settings. “After developing consistent pathways, information can be collected to measure outcomes,” says Dr. Amin. “Processes and protocols can then be refined to further improve the quality of care.”
To establish these protocols, Dr. Pollack suggests that physicians from both specialties, led by a physician champion from each group, meet outside of clinical shift hours to discuss the best available clinical evidence on the evaluation and management of common diagnoses that present to the ED and often require admission. “Buy-in from the entire team is crucial,” he says. “All constituents need to be aware of the increased collaborative efforts and why they’re being implemented. To improve care, standardization must be developed and ongoing. Every EP and hospitalist should be empowered to contribute to these efforts. By harnessing our collective resources and recognizing this important ongoing need, we can avoid working in silos while simultaneously enhancing patient outcomes and satisfaction as well as quality of care.”
Establish a Culture of Collaboration
Dr. Amin adds that both hospitalists and EPs are instrumental in helping their hospitals be successful. “The more these entities collaborate, the more likely that their institutions and their patients will benefit.” Dr. Pollack says the standard care protocol of having EPs only call on hospitalists when patients require admission to the hospital is an obsolete concept. “Through better collaboration between our specialties, there is hope that we can maximize our treatment capabilities for the patients presenting to our institutions. The only way this can happen is if there’s a conscious, deliberate effort to establish a culture of collaboration.”
Readings & Resources (click to view)
Pollack C, Amin A, Talan D. Emergency medicine and hospital medicine: a call for collaboration. The Journal of Emergency Medicine. 2012;43:328-334. Available at www.jem-journal.com/article/S0736-4679%2812%2900140-0/abstract.
Hamel M, Drazen J, Epstein A. The growth of hospitalists and the changing face of primary care. N Engl J Med. 2009;360:1141-1143.
Kuo Y-F, Sharma G, Freeman J, Goodwin J. Growth in the care of older patients by hospitalists in the United States. N Engl J Med. 2009;360:1102-1112.
Pines JM, Batt RJ, Hilton JA, Terwiesch C. The financial consequences of lost demand and reducing boarding in hospital emergency departments. Ann Emerg Med. 2011;58:331-340.
Niska RW, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2010;26:1-31.